Many patients will get temporary relief of their symptoms with conservative measures such as leg elevation, exercise, weight loss and the use of footwear that allows for calf flexion. Patients with more advanced disease may require other interventions such as the use of compression hosiery, catheter ablation, laser therapy, sclerotherapy, microphlebectomy or vein ligation and stripping.
Diagnostic Ultrasound Imaging and Assessment
On your first visit, Dr. Lorenzo will review the pertinent aspects of your medical history and perform a physical exam that is complemented by imaging studies of the affected leg. Fortunately, assessment of the symptomatic patient is non-invasive.
A vascular technologist (also known as an ultrasound technologist) such as Dr. Lorenzo will use an ultrasound machine to generate a Duplex study that will document the anatomy and flow characteristics of the veins in the leg. This is used to rule out any obstruction and abnormal function of the veins in question. In some cases, Dr. Lorenzo may use computed tomography (CAT scan) or magnetic resonance image (MRI) to further evaluate any areas of interest.
Radiofrequency Vein Ablation
A durable treatment for reflux of the saphenous veins or perforator veins can be performed in an office setting. A catheter is inserted into the dysfunctional vein via a puncture site in the skin. Ultrasound imaging is used to guide the catheter into position. Ultrasound waves are then delivered to the lining of the vein causing it to close and collapse. This process is called radiofrequency ablation. Many varicose veins will decompress once the refluxing “feeder” veins are ablated. Radiofrequency ablation can be used to treat superficial veins or the cross-bridging perforator veins between the deep and superficial systems.
Animated videos demonstrating the ablation procedure can be viewed at the following website links:
There are some people with varicose veins that have no associated larger vein dysfunction. (This is common after patients have completed radiofrequency ablation of the saphenous vein.) These types of varicose veins may have become so dilated or thickened that they are too large to be treated with sclerotherapy or laser. In these cases, the best treatment option is microphlebectomy.
Microphlebectomy is the removal of a vein via a small (approximately 1/8 to ¼ inch) incision at the skin surface. A segment of vein is pulled out in each direction and pressure is applied to stop bleeding. Most skin incisions do not require a stitch, but when applicable, the suture is removed in the office in 3 to 4 days. A compression wrap is applied to the leg and can be removed in 72 hours.
If there are few veins to be removed, microphlebectomy can be performed in the office. For larger veins or when multiple areas are to be treated, the procedure is performed in the operating room on an outpatient basis. The risks for microphlebectomy include superficial infection, bruising and hematoma formation (collection of blood under the skin surface).
Because the tissue is so superficial, patients do not have severe pain postoperatively. Most patients report that their pain is well-controlled with anti-inflammatory medication such as ibuprofen (Motrin, Advil). Patients are able to return to work and normal activities in 48 to 72 hours.
Sclerotherapy is an injection treatment used to eliminate small to medium size varicose veins and telangiectasia or “spider” veins. Sclerotherapy is intended to irritate the lining of the vein causing it to scar down and eventually disappear. Sclerotherapy consists of delivery of a chemical into the vein using a very small needle.
The number of treatments necessary to clear or improve the condition differs with each patient and depends on the extent of the varicose and spider veins. One to six or more treatments may be needed, but the average is two to three sessions.
Treatment sessions take approximately 30 to 45 minutes. Your body takes time to respond to the injections and following post-treatment instructions is paramount for achieving optimal results.
Cutaneous Laser Therapy
Laser therapy is best used on veins of very small diameter that are close to the skin surface. The laser consists of a narrow beam of light that targets the vein. As the light is delivered in a series of pulses, it is absorbed at the level of the tissue generating heat. This heat is transmitted to the lining of the blood vessels causing the vessel to collapse.
The majority of spider veins will disappear within 2 to 4 weeks after treatment, but in some cases they take longer. The number of treatments will depend on the size and number of the veins treated. Generally, two to four treatments will be required.
Subendofascial perforator surgery, or SEPS, is a minimally invasive surgical procedure reserved for treatment of patients with refractory venous ulcers. Ulcer formation results from reversed flow from the deep system to the superficial system of veins resulting in high pressure at the skin surface. The reversed flow in the connecting perforator veins can be interrupted, redirecting flow to healthy veins. This will decrease the pressure at the level of the skin and speed healing of the wound.
The SEPS procedure consists of insertion of a small camera into the leg to see the perforator veins. A second instrument is then inserted to divide the perforator vein. A compression wrap is applied postoperatively. The procedure does require anesthesia;;;; SEPS is performed in the operating room on an outpatient basis.
Vein Ligation and Stripping
On occasion, a patient may have vein anatomy that is not conducive to treatment with a catheter. Ligation and stripping may be a more appropriate technique to manage reflux in these patients. This is the procedure whereby the saphenous vein is removed via a small incision in the groin crease and a smaller counter incision below the knee. This can be performed in the operating room as on outpatient procedure.
Graduated Compression Hosiery
Graduated compression hosiery may be prescribed for those patients without arterial disease or decompensated heart failure. The hosiery provides pressure to decrease the volume of blood in the leg thus limiting the amount of venous pooling. This type of hosiery is intentionally designed to provide relatively more compression at the ankle than at the calf or upper part of the leg.
The compression provides relief of pressure for many patients, but will not result in correction of the function of otherwise damaged valves in the veins. Compression hosiery must be fitted to the appropriate size of the patient in order to be effective and not detrimental.
Compression Wrap Application
In cases of venous ulcer formation, wound care consists primarily of cleaning the skin surface of any dead cells and applying pressure to the foot, ankle and leg. This serves to redirect the excess fluid and blood away from the skin to promote better oxygenation of the tissue and to decrease inflammation. It must be performed precisely to avoid trauma to the tissue and exacerbation of tissue swelling. At Vein Care Solutions, wound care is performed by Dr. Lorenzo so that the appropriate amount of cleansing and pressure is applied to speed healing.
Some patients with venous reflux present with severe swelling without varicose veins or ulcers. In the decompensated state this swelling may be severe and may be mistaken for infection. Surgical expertise is necessary to discern between infection and hyperemia (excess amount of blood flow) as well as ruling out other medical conditions that may complicate the condition. Compression wraps may be applied in the acute phase to relieve swelling and prepare the patient’s leg for compression hosiery.